Healthcare Provider Details

I. General information

NPI: 1366364820
Provider Name (Legal Business Name): KIMBERLY JARDINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22365 BARTON RD STE 300
GRAND TERRACE CA
92313-5071
US

IV. Provider business mailing address

3425 RAMONA DR
RIVERSIDE CA
92506-1253
US

V. Phone/Fax

Practice location:
  • Phone: 909-219-5112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95040622
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: